Strengthening WASH Approaches to Improve Nutritional ......place villages; Koukouna from Kapala Commune and Sidiole from Tiemala Banimonotie. USAID/PNH hosted a series of celebrations

JUNE 2019

Undernutrition disproportionately affects the rural poor, trapping families in a vicious cycle of disease and poverty. The USAID Projet Nutrition et Hygiène (USAID/PNH) promoted an integrated nutrition and water, sanitation and hygiene (WASH) approach among target communities to improve nutritional status of children under age 5 and pregnant and lactating women. This technical brief describes the USAID/PNH WASH strategy focused on community and social behavior change.

Strengthening WASH Approaches to Improve Nutritional Status among Women and Children in Sikasso, Mali

LEARNING BRIEF

2 | SAVE THE CHILDREN USAID/PROJET NUTRITION ET HYGIÈNE (PNH)

STRENGTHENING WASH APPROACHES TO IMPROVE NUTRITIONAL STATUS

In an effort to improve the nutritional status of pregnant and lactating women and children under 2 years of age, the USAID/PNH project implemented an integrated approach predicated on social mobilization and behavior change. Save the Children organized the project’s WASH component around the concept of clean household model coupled with support for the government’s community-led total sanitation (CLTS) effort.

CLTS is a participatory rural appraisal technique that engages communities to solve their own problems by using community decision-making and social solidarity to influence individual behavior and achieve results. This facilitated process inspires rural community members to analyze their traditional practice of open defecation, to discuss why it happens, to understand the consequences to their health and to collectively abandon the practice of open defecation and build latrines without any outside subsidy. The project implemented a strong behavior change effort through its community approach that emphasized essential hygiene actions in addition to always using a latrine:

1. Treat drinking water for children under 5 years and households

2. Wash hands at appropriate times before touching food and after defecation

3. Have children (especially those under age 2) play in clean spaces free of feces

4. Ensure mothers have and get their children to use a potty

5. Encourage households to construct handwashing stations and keep them supplied with running water and soap

6. Safely dispose of child feces, either in a latrine or a covered garbage pit.

Global Handwashing Day winners from Farkoba village.

Maman leaders teach about using a children’s potty.

SAVE THE CHILDREN USAID/PROJET NUTRITION ET HYGIÈNE (PNH) | 3


Key WASH ActivitiesCLTS elements reinforced with community behavior change

The centerpiece of the project’s WASH component was supporting the Government of Mali’s effort to implement CLTS. Using the government’s tools, USAID/PNH implemented CLTS in its 236 target villages to stop open defecation and increase the number of latrines and the latrine coverage rate and to improve hygiene practices. The project began by triggering villages—a process that enabled villagers to understand that by defecating in the open they are essentially eating feces. This realization led to a community commitment to end open defection and to support neighbors and family to build latrines.

Triggering activities introduced WASH behaviors that neighborhood nutrition groups for women of reproductive age in the community further reinforced. Through monthly meetings, village women learned how to practice key WASH-related behaviors. They discovered the importance of washing hands before touching food and after visiting the latrine and cleaning a baby, how to properly dispose of infant feces, giving children over 6 months treated drinking water to prevent diarrhea, keeping food hygienic and keeping children’s place spaces clean and free of animal feces.

Community nutrition groups (GSANs) facilitate neighborhood nutrition group sessions and household visits to help caregivers improve their daily household nutrition and hygiene practices. Maman leaders collaborate closely with WASH committee members to reinforce the link between hygiene and nutrition during their neighborhood group meetings. Maman leaders emphasize the importance of washing hands with soap during neighborhood chat sessions and nutrition demonstrations. In addition, they promote safe disposal of feces, while the WASH committee works with community members

CLTS triggering in Kabiola village.

Training masons to construct concrete latrine slabs, Kologo village.

Key WASH Activities

• CLTS elements reinforced with community behavior change

• Village WASH committees

• Post-ODF follow-up activities

• WASH marketing – increasing access to toilets and drinking water treatment



to construct latrines and handwashing stations (tippy taps). Tippy taps are always constructed strategically in front of latrines to spur the adoption of handwashing with soap after using the latrine. Trained in interpersonal communication, mamans leaders negotiate with family members to adopt small doable actions that will lead to better hygiene and fewer cases of illness.

The project followed triggered villages for 3–6 months to monitor progress and guide communities to reach open defecation free status. The first village in the commune reaching ODF status served as the site for a big celebration in which the mayor and dignitaries from the DRACPN came to the village and awarded the certificate in person to all villages in that commune that had reached ODF status. All ODF villages received two signs to post at the entry and exit of the village declaring the community ODF.

USAID/PNH surveyed triggered communities to identify those villages needing improved access to water. The project found approximately 40 communities with non-functional water points that required rehabilitation. Once the village became open defecation free, the project rewarded the community by rehabilitating the water point in need of repair. The project initially rehabilitated 15 water points. In the final year, the project rehabilitated the remaining 26 water points as other donors had repaired several that had been identified.

The project also trained two pump repairers in each commune to be on call to assist villages that need pump repair. In addition, the project supplied each commune with the equipment required to repair the pumps. Communes have agreed to pay to transport the equipment while the village pays the pump repairer from their funds for his time.

Post-ODF certification activity in Tonfa village.

Tippy taps are always constructed strategically in front of latrines to spur the adoption of handwashing with soap after using the latrine.



Village WASH committees

Each village has a village coordination committee with three subcommittees including a WASH committee. Once triggered, during the village coordination committee general assembly meeting, the leadership and community members choose a diverse group of village leaders, community health volunteers, women of reproductive age and adolescents to serve as members of the WASH committee.

The WASH committee organizes WASH activities in the villages and monitors progress to make sure that villagers are engaged in these activities. It is responsible for organizing celebrations to mark Global Handwashing Day and World Toilet Day.

WASH committees are tasked with promoting latrine construction and use and other important hygiene behaviors such as washing hands with soap before touching food and after using the latrine, treating drinking water, practicing food hygiene and keeping the environment free of feces. The WASH committee members conduct home visits to monitor progress, correct behaviors in an effort to maintain a clean and healthy village landscape. WASH committee and maman leaders may visit households jointly to inspect for cleanliness. Some villages are even assessing penalties from 25F to 1,000F (USD 0.50–2.00) for poor hygiene practices. Each committee member is responsible for overseeing five households to promote improved sanitation and handwashing practices and safely disposing of infant feces. They also help households address challenges that may prevent them from building a latrine or participating in WASH activities. In particular, members discuss infant feces and encourage households to purchase child potties for children who are not yet old enough to use a latrine. The presence of child potties has grown exponentially. Currently 14,032 children have potties to discourage

In 2016 after Dierébougou village was certified open defecation free, the USAID/PNH project rehabilitated the village’s water point. The village coordination committee established a WASH committee that initiated a monthly water user fee of 250 FCFA (USD 0.50) per household to ensure good management. M. Bablen, WASH committee chairman remarked, “The rehabilitation of the pump benefited the village. We cannot be healthy if we do not drink potable water. We will take good care of the pump and in case it fails, the water management committee has the funds to repair it.” The committee had saved 110,000 FCFA (USD200) after one year and planned to open a bank account to keep the funds safe.

Women and youth in many villages are in charge of hygiene efforts and have instituted weekly clean up days in anticipation of the Clean Village Competition.



Developing a community action plan.

Mapping feces in a commmunity.

Clean Village Competition Criteria

• Presence and state of latrines

• Functioning WASH committee

• Management of waste water

• Use of child potties

• Animal containment

• Treated drinking water

• Food hygiene

• Community activities

them from defecating on the ground. The caregivers then dump the feces into the latrine rather than leave it on the ground. WASH committees organize village cleaning efforts. In most villages, the committee has designated a weekly cleanup day where village women and adolescent groups sweep the village and put garbage into compost holes. This compost heap can be turned into organic fertilizer that the farmers in the village can use on their community plots.

Communities with a rehabilitated water points have also tasked the WASH committee to act as an overseer of that water point. In these villages, community members contribute to a monthly water fund to support future repairs and maintenance required to keep the water point functional. The rehabilitated water points also help motivate villagers to stay accountable to their WASH plans

Post-ODF follow-up activities

To combat this recidivism, the Government of Mali with support from USAID launched a post-ODF campaign to motivate and encourage communities to maintain their open defecation free status. The Government of Mali’s Directorate of Sanitation Pollution and Nuisance Control (DNACPN) organized a Clean Village Competition with technical and financial support from UNICEF, USAID and its partners. The competition was held nationally in four regions of Mali: Kayes, Koulikoro, Mopti and Sikasso to boost implementation of post-ODF action plans. The preparation phase established the commission and subcommittees. The competition was launched in each region in August 2018 where all certified ODF villages were invited to participate. Villages were encouraged to carry out a Knowledge Attitude and Practices survey, develop their post-ODF plan to maintain ODF status, and register in the national SANIYA database. Commission members visited the participating villages and rated them against a common set of criteria. The top scoring villages received prizes to recognize their efforts in maintaining ODF status.



From August through November 2018 inspectors visited villages participating in the competition twice and scored them on a 90 point scale using the criteria listed in the box. The competition inspired community members to self-monitor WASH efforts in the village and encouraged them to restructure village norms. The three winners in Sikasso Region scored between 79 and 87 points and were honored at a celebration on World Toilet Day, 19 November 2018. The government supported the grand prize winner, Kouniana village from Kouniana Commune, while USAID/PNH supported both the second and third place villages; Koukouna from Kapala Commune and Sidiole from Tiemala Banimonotie. USAID/PNH hosted a series of celebrations for the top three winners from each commune in Bougouni and Sikasso districts.

WASH marketing — increasing access to toilets and drinking water treatment

The project has always coupled safe drinking water as part of improved sanitation and hygiene practices. To spur WASH marketing activities, the USAID/PNH project launched a revolving program for WASH committees to promote water treatment with Aquatabs. All target villages have received a supply of the product to sell to villagers at a nominal fee (less than market rate) to instill treating drinking water as a habit. While the project promotes it for pregnant/lactating women and young children, all family members can benefit. The WASH committees offers the tablets for 10F and creates a revolving fund to purchase additional supplies through a partnership framework with the USAID/KJK project. The WASH committee can keep a small profit to use to support other WASH activities in the village.

USAID/PNH also trained masons to build latrines and SanPlat slabs using local materials. In each village craftsmen attended CLTS triggering events and then offered their latrine construction skills and services to newly interested households. Each village has received a SanPlat slab construction kit that the trained masons can access to create new latrines for their community. The latrines are affordably priced and over time, the hope is that villagers will aspire to constructing improved latrines.

Village leaders celebrate their community earning open defecation free status.

A trained mason making a latrine slab.



Promoting SustainabilityTo promote sustainability, USAID/PNH assisted the WASH committees to develop community WASH plans and then as a group advocate with the commune leadership to include WASH as a budget line item in commune plans.

Community WASH plans

The WASH committee conducts a community diagnosis to identify and prioritize WASH issues and determine the root causes of these issues. Committee members and villagers then create a community action plan on how to tackle and prioritize WASH issues and how to measure progress over time. The VCC and the WASH committee validates the plan before launching any WASH activities. Each WASH committee meets monthly to review its plan and monitor progress. By engaging the community in addressing WASH issues and giving them to tools to mobilize to tackle problems better, communities are seeing real improvements. Villages are reaching ODF status by remaining accountable to the WASH action items listed in their plans. Moreover, WASH committee efforts are generating community-wide pride as villagers see that by working together and mobilizing their own resources, they can improve their own hygiene and the health of the village.

Commune WASH commitments

USAID/PNH engaged in advocacy to include nutrition and WASH in communal development plans to pressure communities to sustain and continue to improve on the gains that have been achieved in nutrition and WASH over the life of the project. Encouraging communities to add nutrition, WASH, and agriculture in their community development plans pushes officials at the commune level to include budget line items for these areas at the commune level as well. As a strategy to maintain WASH gains beyond

Teaching youth about feces as they are learning to become adults we hope will be instrumental in the future to changing and maintaining the new social norms that encourage latrine use, regular handwashing with soap and treating drinking water all in a clean environment.

Radio Reinforces Behavior Change

Mariko Waraba tells the WASH committee visitors that she started listening to the radio programs on nutrition and hygiene while cooking with her sister-in-law. She and her friends talk about the messages in her neighborhood group. “I have learned how to give my children nutritious food and make sure my family is clean and healthy.” Men are also listening to these messages and they are newly interested in feeding their children good food. The radio programs support the neighborhood activities led by maman leaders. She proudly shows how healthy her children are.



the life of the project, the USAID/PNH project established a process to engage local officials in recognizing the importance and causes of malnutrition in their communities and committing to an action plan that includes funding opportunities at the commune level to promote the management of malnutrition.

To reach a larger audience with messages about the importance of good hygiene, the project also broadcast radio programs on nutrition and WASH across the project target area supporting the range of nutrition, WASH and agriculture behavior change efforts. Project staff have monitored broadcasts to ensure that all target areas heard the spots and magazines.

ResultsUSAID/PNH certified 207 villages as ODF helping communities oversee the construction or rehabilitation of 5,011 latrines and 7,799 handwashing stations. The project has supported over 137,000 people to gain access to a latrine and over 27,000 people to gain access to an improved water source. With improved hand-washing practices and access to clean water at the community level, the project has contributed to a 22 percent decline in underweight in children under 0–59 months and a 41 percent decline in wasting.

In anecdotal conversations with community members, WASH activities represent the most visible changes since the project began. This result is further supported by the external USAID-funded evaluation that found a “general perception that the incidences of diarrhea had been dramatically reduced in their communities since the collective response to WASH was started.” Men in the community note that they see a difference in the cleanliness of their villages and they remark that they are paying less in health center visits. Women and youth in many villages are in charge of hygiene efforts and have instituted weekly clean up days in anticipation of the Clean Village Competition that took place in 2018.

WASH Behavior Change Results

• Women washing hands after toilet increased by 25 percentage points.

• Women washing hands before eating increased by 40 percentage points

• Women washing hands before preparing food increased by 9 percentage points

• 98% of respondents used a basic or improved latrine

• Safe disposal of infant feces increased by 32 percentage points

• Families treating drinking water increased by 9 percentage points

—Results from the project-supported mid-term evaluation

Chat sessions (left) and handwashing demonstrations (above) improved community participation in handwashing at important times.



Best Practices / Lessons LearnedLatrine construction reinforced by CLTS and Clean Village Competition. CLTS is a social mobilization approach that sensitizes individuals about the dangers of ingesting fecal matter and promotes all households in a village to construct a latrine in the compound. The iterative process of checking on progress coupled with strengthening WASH committees to self-monitor progress toward the goal of becoming an open defecation free community reminds households to construct or rehabilitate latrines. The drive to become a recognized ODF community further motivates households to comply with village recommendations and helps to change social norms. The presence of trained masons who can provide cement platforms also improves the uptake and construction of basic and improved latrines. Finally WASH committees have determined that non-compliance should be addressed by imposing fines. As one village chief noted during the USAID-funded external evaluation, “The WASH committee chairman noticed some households were slow to build latrines and asked me to order fines for those who don’t build or repair them.”

WASH efforts offer opportunities to address gender norms. The project coupled weekly environmental cleaning activities with conversations about gender roles and responsibilities in WASH. These question-based conversations led villagers to discuss how to engage men in areas traditionally regarded as a “women’s domain” and have spurred women and men to question traditional gender roles and identify ways that men can work with women to support WASH in the communities. Similarly, management of village affairs was usually considered a man’s job. Now women are active members of WASH committees and often lead the charge in conducting community diagnoses to identify and prioritize WASH issues, promoting water treatment with Aquatabs, and mobilizing communities to participate in inter-village WASH competitions. In Bougouni district women lead half of all WASH committees in targeted villages. Further, the engagement of adolescents in these efforts may encourage girls and boys to continue to question traditional gender norms and begin to institute incremental changes in social norms as they grow within the community.

Engaging youth in WASH promotes community pride and good practice. The WASH committees supported by maman leaders engaged the energy and passion of village youth to beautify their communities as they sought to become open defecation free. Village leaders also challenged adolescent boys and girls to propose projects to support communities in their effort to achieve meet the criteria established for the Clean

Active members of WASH committees often lead the charge in activities such as promoting water treatment with Aquatabs.



WHAT IS USAID/PNH?

The USAID-funded Project Nutrition and Hygiene (PNH) managed by Save the Children with partner SNV aims to improve the nutritional status of pregnant and lactating women and children under two years of age in six health districts of the Sikasso

Region, Mali. It is agriculturally productive, a center for trade, and one of the most densely populated regions of Mali. Over the course of six years, the project aims to reach at least 10,000 pregnant and lactating women (PLW) and 50,000 children under 2 years of age with a full package of interventions.

This brief is made possible by the generous support of the American people through the United States Agency for International Development (USAID) Bureau for Global Health under terms of Cooperative Agreement No. AID-688-A-13-00004. The contents are the responsibility of Save the Children, and do not necessarily reflect the views of USAID or the United States Government.

For more information, contact: PNH Project, Save the Children, Village CAN Rue 356 Porte 123 Wayerma, Sikasso

Bamako

Mali

SIKASSO

Village Competition. As integral collaborators in the weekly village cleaning efforts such as sweeping trash and debris and ensuring that animal feces is properly disposed, adolescents understand the importance of a clean environment. Engaging youth as they are learning to become adults we hope will be instrumental in the future to changing and maintaining the new social norms that encourage latrine use, regular handwashing with soap and treating drinking water all in a clean environment.

Commune engagement in community WASH programming promotes continued adherence to improved sanitation and hygiene. The Social, Economic and Cultural Development Plan (PDSEC), is a five-year work plan created by the commune that considers the concerns of all communities. Between October and December of each year, commune officials design the annual action plan and budget for priority activities. Commune and state officials and partner NGOs monitor the progress during the year. In 2016, the project advocated for including WASH activities in the PDSEC. The active involvement of communities in the larger PDSEC planning not only created better avenues of collaboration between the village WASH committees and government officials, but also ensured communities had a voice in prioritizing issues they considered the most important.

Conclusion The increasing number and variety of the stories from the field demonstrate that while behavior change does take time, systemic and transformative change is taking place at the village level. USAID/PNH has made progress in promoting essential actions in hygiene and a clean environment and most project communities are proud to be open defecation free. WASH committees are led by women in many villages. The most visible changes come from sanitation. Men see that their villages are cleaner and they equate this with the reduction in household spending for health services. Children under five use small potties and almost all villages have weekly cleaning days. Perhaps most significantly the change is happening within the cultural context as much as among individuals who are eating better, practicing improved hygiene, and retaining more food for the family. Men are accepting their roles in ensuring improved WASH, women are instrumental in WASH committees and local government and technical services are empowered to monitor ODF status to ensure that all benefit from improve health outcomes.

STRENGTHENING WASH APPROACHES TO IMPROVE NUTRITIONAL STATUSThe increasing number and variety of the stories from the field demonstrate that while behavior change does take time, systemic and transformative change is taking place at the village level. USAID/PNH has made progress in promoting essential actions in hygiene and a clean environment and most project communities are proud to be open defecation free.

Documents

Strengthening WASH Approaches to Improve Nutritional ......place villages; Koukouna from Kapala Commune and Sidiole from Tiemala Banimonotie. USAID/PNH hosted a series of celebrations